MEDICARE: SOUTHERN PAIN AND SPINE ASSOCIATES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208VP0014X	Interventional Pain Medicine Physician
2	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1700742616
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN PAIN AND SPINE ASSOCIATES, LLC

Provider Business Mailing Address
First Line	:	1101 OLD PHILADELPHIA RD STE G100
Second Line	:
City	:	JASPER
State	:	GA
Zip	:	30143-4044
Country	:	US
Telephone Number	:	678-971-4167
Fax Number	:	833-989-2501

Provider Business Practice Location Address
First Line	:	1101 OLD PHILADELPHIA RD STE G100
Second Line	:
City	:	JASPER
State	:	GA
Zip	:	30143-4044
Country	:	US
Telephone Number	:	678-971-4167
Fax Number	:	833-989-2501

Authorized Official
Title or Position	:	CEO / MANAGING PARTNER
Name	:	ANKUR BHARAT PATEL
Credential	:	MD
Telephone Number	:	678-971-4167

Provider Enumeration Date	:	01/05/2026
Last Update Date	:	01/05/2026

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